Overview of Strategies and Treatment Approaches for Children with Autism Spectrum Disorders
There are numerous instructional approaches, treatment protocols, and specialized programs specifically designed for children with autism spectrum disorders. The evidence for the effectiveness of methods rooted in Applied Behavior Analysis is extensive:
“No other educational or treatment approach to autism meets the standards of scientific proof that are met by ABA and there are no other scientifically valid treatments for autism that produce similar treatment, educational, or outcome results” (Jacobson, Foxx & Mulick, ControversialTherapies for Developmental Disabilities: Fads, fashion and science in professional practice, Mahwah, NJ: Lawrence Erlbaum Associates, 2005.)
In addition to methods that fall under the “umbrella” of ABA, other strategies may be considered when developing personalized programs for young children with autism spectrum disorders.
Provided below is a list followed by brief descriptions of some interventions that have much attention in recent years: •Applied Behavior Analysis
o Natural Environment Strategies
o Discrete Trial Training
o Errorless Learning
o Verbal Behavior Analysis/Mand Training
o Picture Exchange Communication System (PECS)
o TEACCH strategies
o Positive Behavioral Support
•Family-Guided Routines-Based Intervention •Floortime/DIR (Developmental, Individual-Difference, Relationship-Based) •Relationship Development Intervention •Integrated Play Groups Model •Sensory Intervention Plans •Assistive Technology
It should be noted that different approaches or models use some of the same strategies and are based on similar principles. The approaches may differ on a number of variables such as:
•Teacher versus child initiation for interaction
•Use of secondary reinforcement versus naturally occurring consequences
•Use of elicited responding versus modeling
•Use of predetermined stimulus material versus naturally occurring environmental stimuli
•Predetermined sequence of instruction versus variable sequence of instruction
•Goal selection based on didactic principles versus the sequence of normal development
Applied Behavior Analysis
“Applied Behavior Analysis (ABA) is the science in which procedures derived from the principles of behavior are systematically applied to improve socially significant behavior...” (Baer, Wolf, and Risley, 1968). The defining assumption of ABA is that behavior is learned and controlled by contingencies within the environment. ABA practitioners maintain close and continual contact with relevant outcome data in order to make empirical-based decisions across individual programs. There are numerous teaching procedures and practices that have evolved from the science of ABA that have been shown to be effective with children with developmental disabilities, predominantly autism spectrum disorders. These different applications, including but not limited to natural environment strategies, discrete trial training, errorless learning, and verbal behavior analysis, are considered when developing individualized educational programs for children.
Natural Environment Strategies
Natural Environment Strategies include several specific methodologies derived from Applied Behavior Analysis including “Incidental Teaching” and “Pivotal Response Training,” which target global deficits such as motivation, initiation, engagement, and attention to multiple and relevant cues, as well as individual skill sets. Natural Environment Strategies are child-directed and target language skills within naturally contrived opportunities throughout the day. These methodologies have been shown to be very effective for many children with autism spectrum disorders and as a model for parent training.
•A natural environment is arranged to attract children to desired materials and activities
•The child initiates the teaching process by indicating an interest in an item or activity
•The teacher uses the child’s initiation as a teaching opportunity
•The child’s response results in a natural consequence, contingent access to the item or
activity of interest.
Discrete Trial Training
Derived from Applied Behavior Analysis, Discrete Trial Training is a method of instruction in which skills are broken down into teachable steps, then presented and reinforced in a repetitive fashion until the student demonstrates mastery of the skill (ex. teacher presents a question or instruction -->student responds --> teacher presents appropriate consequence). 3-Step Guided Instruction is a form of Discrete Trial Training that uses systematic least-to-most prompting that ensures follow-through and access to reinforcement based on level of independence.
•Say (provide verbal instruction) ex: “point to ball.” If student responds correctly, provide reinforcement. If incorrect or no response...
•Show (restate verbal instruction and provide a visual cue) ex: “point to ball” then point to the ball as a model. If student responds correctly, provide reinforcement. If incorrect or no response...
•Do (restate verbal instruction and provide a physical prompt) ex: “point to ball” then guide the student’s hand to point to the ball. No reinforcement is provided for physically prompted responses.
Errorless Learning
Errorless Learning is an instructional procedure derived from the field of Applied Behavior Analysis that is similar to Discrete Trial Teaching, but uses prompts in a most-to-least fashion in order to elicit only correct responses. Prompted trials are followed by less prompted or “transfer” trials until the student demonstrates mastery of the skill. Specific reinforcement and momentum strategies are used to combat prompt-dependency and keep the child motivated through teaching sessions. Errorless learning is considered when least-to-most teaching procedures are determined to be ineffective for individual students.
Verbal Behavior Analysis
Verbal Behavior Analysis (VBA) uses the principles of Applied Behavior Analysis and focuses on the development of functional communication by establishing motivating conditions in which to teach language. This approach is based on B.F. Skinner’s analysis of verbal behavior and uses errorless learning and specific quick-transfer procedures within the natural environment as well as during intensive teaching sessions. At the core of this analysis is the distinction between the mand (i.e. requesting), tact (i.e. labeling, commenting), and intraverbal (i.e. responding to questions). Children with no spoken language are often taught to use sign language, when appropriate, as a jump-start to functional communication and a bridge to spoken language with a strategy called “mand training.” This intensive technique targets items or activities of high interest in order to motivate the child to request items and activities in his/her environment many times throughout the day.
Picture Exchange Communication System
The Picture Exchange Communication System, otherwise known as PECS, is a structured training program that teaches children to communicate by selecting picture symbols or words from a visual display and handing them to a communication partner. There is a specific progression of teaching phases that first focuses on establishing the ‘exchange’, and builds up to picture discrimination and language expansion. PECS is widely used with children with autism due to the frequent difficulties that many children encounter with developing purposeful pointing skills and verbal language. Some parents worry that PECS will prevent their child from using spoken language. Research supports the opposite conclusion – children who have developed some means of communication, even if it is nonverbal, will more quickly increase speech skills.
Treatment and Education of Autistic and related Communication handicapped CHildren (TEACCH strategies)
The TEACCH program, developed at the University of North Carolina, provides individualized instruction emphasizing completion of independent work tasks presented in highly structured learning environments. TEACCH practitioners develop clearly defined workstations, utilize
individual picture schedules, and organize instructional materials in a clear visual manner. Many TEACCH strategies, primarily the development of highly structured visual-based systems, are considered when developing individualized educational programs for children with autism spectrum disorders.
Positive Behavioral Support http://www.apbs.org/new_apbs/autismdesc.aspx
Positive Behavioral Supports are used within a program to promote behavioral change. These supports are driven by a thorough understanding of the problem behavior and its function. Reduction of problem behaviors is a result of ongoing team analysis and problem solving to develop preventative strategies, teach alternative skills, design crisis management procedures, and modify contingencies in the child’s environment. The positive behavioral supports approach holds a broadened view of intervention success by evaluating whether improvements in the use of alternative behaviors have been maintained across time and generalized across settings, whether improvements have occurred in the child’s quality of life, and whether the intervention has positively impacted on the child’s health and well-being.
Family-Guided Routines-Based Intervention
Family-guided routines based intervention is a systematic approach to embed intervention consistently by all family members and service providers throughout the day rather than in individual, isolated therapy sessions. Routines are functional events of daily living that offer opportunities to teach and practice meaningful skills in settings and situations, as they are needed. By definition, they occur on a regular basis and are repeated frequently, offering multiple opportunities for teaching and learning. Family-guided routines are those functional and predictable activities that match the interests and individual schedules of the child and family. The family guides the selection of appropriate targets and contexts for intervention. Routines that are selected for intervention are predictable and positive for both the child and care provider to enhance the ease of use and the potential for positive outcomes.
Developmental, Individual differences, Relationship-based (DIR) Approach
The Developmental, Individual differences, Relationship-based (DIR) Approach was developed by Drs. Stanley Greenspan and Serena Wieder and focuses on the child’s social-interaction development, primarily the core processes of relating, attending, communicating, and thinking. These processes are targeted through a set of strategies known as “floortime” play with the child. “Floortime” is a series of reciprocal child-directed interactions resulting in “communication circles.” The goal of “floortime” is to sustain interactions between the child and the adult by gradually increasing the circles of communication. These interactions become the basis for further play development.
During “floortime,” the adult joins in the child’s play to increase opportunities for pleasurable interaction and engagement. The child’s actions are considered intentional and purposeful. The adult follows the child’s lead to validate the child’s sense of “self.” Preferred objects and activities are used to motivate the child and facilitate persistence and patience. Higher level skills and concepts are taught through interactive play.
Relationship Development Intervention (RDI)
Relationship Development Intervention is a cognitive-developmental treatment program developed by Dr. Steven Gutstein. RDI focuses on family empowerment in which parents are trained to act as participant guides, creating daily opportunities for their child to respond in more flexible, thoughtful ways to novel, challenging and increasingly unpredictable settings and problems. The RDI approach targets core areas of “dynamic intelligence” including declarative communication, referencing, regulating, episodic memory, and flexible thinking. Parents are taught to re-think their daily lifestyle, structuring activities throughout the day to provide safe, but challenging opportunities for discovery.
Integrated Play Groups Model
The Integrated Play Groups Model was developed by Dr. Pamela Wolfberg at San Francisco State University to enhance peer relations and social development in children with autism. The model consists of three main steps, including thorough assessment, play group development, and guided participation. IPG assessments identify the child’s level of functioning and preferences across several skill areas and play domains. Integrated playgroups, consisting of a small group of children with diverse abilities, are then specifically tailored around the child’s strengths, interests, and target objectives. Play sessions are structured by establishing routines and rituals that foster familiarity, predictability and a cohesive group identity with an emphasis on using visual aids. Guided participation is enacted through a carefully designed system of support. The play guide methodically guides novice and expert players to engage in mutually enjoyed play activities that encourage social interaction, communication, play and imagination. Play guides apply a key set of practices including monitoring play initiations, scaffolding play, and providing social-communication and play guidance.
Sensory Intervention Plans
Sensory processing refers to the ability of the central nervous system to take in and respond to environmental input from all of the senses, including vision, hearing, touch, responses to movement and pressure on the body, taste, and smell. Self-regulation refers to the ability to maintain a calm, alert, and attentive state, which promotes involvement in learning experiences and interaction with others. Many people with autism are believed to demonstrate atypical reactions to sensory input. The self-stimulatory or perseverative behaviors exhibited by persons with autism are possibly attempts to seek out calming and organizing sensory input or to avoid disorganizing input from the environment. Examples of difficulty with sensory processing and self-regulation may include:
• Excessive jumping, running, or spinning which indicates a need for vestibular (movement of the head through space) and proprioceptive (movement and position of the body) input
• Biting, sucking, and chewing excessively which indicates a need for proprioceptive input through the mouth
•Excessive toughing or avoidance of touching which indicates atypical reactions from the tactile (touch) system
• Agitated behavior or under-responsive behavior in loud, crowded, or visually stimulating situations which indicates over-reactivity to noise, touch, or visual input.
Difficulties with sensory processing and self-regulation can be addressed through careful assessment of the individual student’s needs. A sensory intervention plan is developed based on the specific sensory needs of the child. The learning environment is modified to reduce sensory defensiveness and enhance self-regulation. Specific activities are planned throughout the student’s day to promote better attention and engagement in learning.
Assistive Technology
Assistive technology is any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. The most widely used assistive technology applications for young children with autism include those that address communication skills.
Low Tech Augmentative Communication Aids
Strategies and devices that supplement speech skills are typically termed “augmentative communication” approaches. Materials that do not have electronic components are often referred to as “low tech” augmentative communication aids and include picture symbol communication boards and books. For preliterate children, words and concepts are represented by photographs or picture symbols which accompany the printed words. Messages are communicated by pointing to the corresponding picture symbols or by handing the picture symbol to a communication partner.
High Tech Voice Output Communication Aids
Augmentative communication devices, which have electronic components, are often referred to as “high tech.” Those devices permit an adult to program corresponding spoken messages for the picture symbols selected for the child. The child is able to communicate the messages by selecting a picture symbol. The spoken message often provides a model for the child and cues the child to say the word or phrase. Use of the voice output communication device also permits the child to communicate more effectively in group situations than use of low tech communication aids.
Teaching Strategies from Council for Exceptional Children Website
When teaching students with autism, educators must consider the child's social, communication, and academic needs. Thus, teachers must offer a broad array of accommodations to help them cope with the turmoil of school interactions, as well as provide structure and adaptations that enable them to master subject content.
To start, Shore recommends that teachers observe their students with autism to learn how they react in particular situations and their likes and dislikes. Shore also cautions that teachers must not see these students as a bundle of symptoms.
"A student with autism is a thinking person, not a collection of behaviors that need to be changed," he says.
Some additional strategies to help students with autism succeed are:
Organization and Structure
Provide visual cues. Since most students with autism are visual learners, visual cues can be a lifeline. They inform students of the rules, their schedule, and changes in their routine. For example, the teacher can create a person locator system on a bulletin board, which shows students what they will do and with whom that day, says Simpson. If a teacher will be absent, take the teacher's picture off and tell the student, "In her place, we have Mr. Todd."
Visual supports can also be used for task analysis, says Simpson. For free time, the cue may show a picture of activity choices such as a computer or book. Then the visuals outline the steps to take: get material, sit in this area and work on item one, clean up, return to seat.
Don't remove visual supports too soon. Instead, find ways the students can be more independent by using them. While it's cumbersome to carry around a Velcro board outlining the day's schedule, students could use something like a day planner, recommends Simpson.
Provide appropriate levels of structure. Set up routines for class activities such as writing on the board an outline of what was covered yesterday, what the class will do today, and what that will lead to tomorrow.
Use schedulers or organizers to help students keep track of their activities for a day.
Academic Accommodations
Many of the academic strategies that work for students with autism are those used with students with learning disabilities, such as:
Write down lesson objectives.
Provide keyboards. Students with autism often have difficulty writing, which impedes their ability to take notes or write long assignments. Other options include a peer note-taker or providing advance notes, which help students with structure and content mastery.
Use priming techniques. Familiarize students with material before it is introduced in class and show how new content fits into previous knowledge. This prevents students from shutting down when new material is introduced. Or, review the schedule at the beginning of the school day, which gives the student a heads up on upcoming assignments, books, and activities.
Provide extra testing time and verbal tests.
Use graphic organizers and highlight significant concepts. This prevents students from focusing on minutia.
Use peer buddies who prompt students to follow verbal directions.
Teach the hidden curriculum - what is important to certain teachers and social protocols.
Use the students' interests to relate to content.
Ask students what they need: where they are comfortable sitting, what they need for lectures.
Consider a reduced schedule or scheduling the student's most difficult class later in the day.
Make sure the student understands the content when the lesson moves to abstract concepts.
Behavior Control
Conduct functional behavior assessments. Some children with autism have "odd behaviors they use to communicate," says Grimm. Students may hit or grab someone when unsure what will happen next or if they are thirsty and can't ask for a drink. Communication is further complicated by the fact that the same behavior may have different functions in different settings. Once the teacher determines the behavior's function, he or she should develop a functional communication system for the student. Both the assessment and communication system should be set up before the child is placed in an inclusive class, Grimm says.
Have a home base for students. Home base is a place where students can go to regroup when they become overstressed. Students can also go there to review and interpret the day's events, says Myles. Home base should never be used as punishment.
Allow students to change classes early or pair with another student, so they don't feel overcrowded in the halls.
See "Meltdowns" for recommendations for these behaviors. Social Skills Use the student's interests to help them make friends, e.g. find a club the student could join.
Do "social autopsy." Help the student analyze a situation, discover what went wrong, develop alternate solutions, and plan strategies to use when similar situations occur. The teacher may want to write down the strategies so the student has a script of what to say.
Set up social skills groups in which the student can learn and practice social skills. The group may include students with autism and general education students who serve as role models or others who are shy or otherwise need help with social skills.
Offer alternatives to stressful situations such as the lunchroom, gym, or other places that are noisy, have lots of sensory input, and require students to interact with peers on their own. Allow the student and a few others to eat in a smaller room where social skills can be practiced. For gym, give the student head phones or make another student a buddy and perform a physical activity in another location.
Provide peer buddies. Have general education students work as social translators for students with autism.
Allow students to role play social situations to learn appropriate ways to interact with others and make friends.
Provide group work. While group work is critical, Safran says, it must be done with care. The student with autism should have a peer buddy, or the teacher should pre-define student roles. The student with autism should be assigned specific tasks and someone should monitor his or her progress. A good way to prepare students for group work is through role playing.
Give students visual cues to help them deal with different social situations, says Webber. Cards the teacher provides would give the student various responses to specific situations.
Use social stories to help students learn how to make friends.
New Strategies
Some new strategies have emerged that may further help students with autism. New York University's Barbara Hummel-Rossi developed a methodology that enables students with autism to problem solve. It allows them to explore on their own while providing support. The student is given a task and a set of materials with which to work to reach a solution. Afterwards, the students can use the problem solving process they learned in new situations.
The Miller Method is a cognitive development technique that uses the student's desire to do something to teach communication. Here the instructor teaches the student a routine for an enjoyable activity, such as going down a slide. After the student knows the routine, the teacher interrupts at the moment of maximum tension, when the student most wants to continue the activity. This is where we have the greatest likelihood of communication, says Shore. When the student realizes he or she is stopped - and before the tantrum - there will be communication.
Videos are also being used to help students with autism learn social skills. A program developed by Lisa Burger, Jeanine Thomas, and Ann Bodden-Griffen of Easter Seals DuPage, Ill., combines a video of a social interaction such as playing doctor, a written script, and occupational therapy (OT). The OT helps the children be ready to learn; the script, in the form of a picture book, provides visual reinforcement for the video; and the video shows the students what to do and say in an interaction.
Overview of Strategies and Treatment Approaches for Children with Autism Spectrum Disorders
There are numerous instructional approaches, treatment protocols, and specialized programs specifically designed for children with autism spectrum disorders. The evidence for the effectiveness of methods rooted in Applied Behavior Analysis is extensive:
“No other educational or treatment approach to autism meets the standards of scientific proof that are met by ABA and there are no other scientifically valid treatments for autism that produce similar treatment, educational, or outcome results” (Jacobson, Foxx & Mulick, Controversial Therapies for Developmental Disabilities: Fads, fashion and science in professional practice, Mahwah, NJ: Lawrence Erlbaum Associates, 2005.)
In addition to methods that fall under the “umbrella” of ABA, other strategies may be considered when developing personalized programs for young children with autism spectrum disorders.
Provided below is a list followed by brief descriptions of some interventions that have much attention in recent years:
•Applied Behavior Analysis
o Natural Environment Strategies
o Discrete Trial Training
o Errorless Learning
o Verbal Behavior Analysis/Mand Training
o Picture Exchange Communication System (PECS)
o TEACCH strategies
o Positive Behavioral Support
•Family-Guided Routines-Based Intervention
•Floortime/DIR (Developmental, Individual-Difference, Relationship-Based)
•Relationship Development Intervention
•Integrated Play Groups Model
•Sensory Intervention Plans
•Assistive Technology
It should be noted that different approaches or models use some of the same strategies and are based on similar principles. The approaches may differ on a number of variables such as:
•Teacher versus child initiation for interaction
•Use of secondary reinforcement versus naturally occurring consequences
•Use of elicited responding versus modeling
•Use of predetermined stimulus material versus naturally occurring environmental stimuli
•Predetermined sequence of instruction versus variable sequence of instruction
•Goal selection based on didactic principles versus the sequence of normal development
Applied Behavior Analysis
“Applied Behavior Analysis (ABA) is the science in which procedures derived from the principles of behavior are systematically applied to improve socially significant behavior...” (Baer, Wolf, and Risley, 1968). The defining assumption of ABA is that behavior is learned and controlled by contingencies within the environment. ABA practitioners maintain close and continual contact with relevant outcome data in order to make empirical-based decisions across individual programs. There are numerous teaching procedures and practices that have evolved from the science of ABA that have been shown to be effective with children with developmental disabilities, predominantly autism spectrum disorders. These different applications, including but not limited to natural environment strategies, discrete trial training, errorless learning, and verbal behavior analysis, are considered when developing individualized educational programs for children.
Natural Environment Strategies
Natural Environment Strategies include several specific methodologies derived from Applied Behavior Analysis including “Incidental Teaching” and “Pivotal Response Training,” which target global deficits such as motivation, initiation, engagement, and attention to multiple and relevant cues, as well as individual skill sets. Natural Environment Strategies are child-directed and target language skills within naturally contrived opportunities throughout the day. These methodologies have been shown to be very effective for many children with autism spectrum disorders and as a model for parent training.
•A natural environment is arranged to attract children to desired materials and activities
•The child initiates the teaching process by indicating an interest in an item or activity
•The teacher uses the child’s initiation as a teaching opportunity
•The child’s response results in a natural consequence, contingent access to the item or
activity of interest.
Discrete Trial Training
Derived from Applied Behavior Analysis, Discrete Trial Training is a method of instruction in which skills are broken down into teachable steps, then presented and reinforced in a repetitive fashion until the student demonstrates mastery of the skill (ex. teacher presents a question or instruction -->student responds --> teacher presents appropriate consequence). 3-Step Guided Instruction is a form of Discrete Trial Training that uses systematic least-to-most prompting that ensures follow-through and access to reinforcement based on level of independence.
•Say (provide verbal instruction) ex: “point to ball.” If student responds correctly, provide reinforcement. If incorrect or no response...
•Show (restate verbal instruction and provide a visual cue) ex: “point to ball” then point to the ball as a model. If student responds correctly, provide reinforcement. If incorrect or no response...
•Do (restate verbal instruction and provide a physical prompt) ex: “point to ball” then guide the student’s hand to point to the ball. No reinforcement is provided for physically prompted responses.
Errorless Learning
Errorless Learning is an instructional procedure derived from the field of Applied Behavior Analysis that is similar to Discrete Trial Teaching, but uses prompts in a most-to-least fashion in order to elicit only correct responses. Prompted trials are followed by less prompted or “transfer” trials until the student demonstrates mastery of the skill. Specific reinforcement and momentum strategies are used to combat prompt-dependency and keep the child motivated through teaching sessions. Errorless learning is considered when least-to-most teaching procedures are determined to be ineffective for individual students.
Verbal Behavior Analysis
Verbal Behavior Analysis (VBA) uses the principles of Applied Behavior Analysis and focuses on the development of functional communication by establishing motivating conditions in which to teach language. This approach is based on B.F. Skinner’s analysis of verbal behavior and uses errorless learning and specific quick-transfer procedures within the natural environment as well as during intensive teaching sessions. At the core of this analysis is the distinction between the mand (i.e. requesting), tact (i.e. labeling, commenting), and intraverbal (i.e. responding to questions). Children with no spoken language are often taught to use sign language, when appropriate, as a jump-start to functional communication and a bridge to spoken language with a strategy called “mand training.” This intensive technique targets items or activities of high interest in order to motivate the child to request items and activities in his/her environment many times throughout the day.
Picture Exchange Communication System
The Picture Exchange Communication System, otherwise known as PECS, is a structured training program that teaches children to communicate by selecting picture symbols or words from a visual display and handing them to a communication partner. There is a specific progression of teaching phases that first focuses on establishing the ‘exchange’, and builds up to picture discrimination and language expansion. PECS is widely used with children with autism due to the frequent difficulties that many children encounter with developing purposeful pointing skills and verbal language. Some parents worry that PECS will prevent their child from using spoken language. Research supports the opposite conclusion – children who have developed some means of communication, even if it is nonverbal, will more quickly increase speech skills.
Treatment and Education of Autistic and related Communication handicapped CHildren (TEACCH strategies)
The TEACCH program, developed at the University of North Carolina, provides individualized instruction emphasizing completion of independent work tasks presented in highly structured learning environments. TEACCH practitioners develop clearly defined workstations, utilize
individual picture schedules, and organize instructional materials in a clear visual manner. Many TEACCH strategies, primarily the development of highly structured visual-based systems, are considered when developing individualized educational programs for children with autism spectrum disorders.
Positive Behavioral Support
http://www.apbs.org/new_apbs/autismdesc.aspx
Positive Behavioral Supports are used within a program to promote behavioral change. These supports are driven by a thorough understanding of the problem behavior and its function. Reduction of problem behaviors is a result of ongoing team analysis and problem solving to develop preventative strategies, teach alternative skills, design crisis management procedures, and modify contingencies in the child’s environment. The positive behavioral supports approach holds a broadened view of intervention success by evaluating whether improvements in the use of alternative behaviors have been maintained across time and generalized across settings, whether improvements have occurred in the child’s quality of life, and whether the intervention has positively impacted on the child’s health and well-being.
Family-Guided Routines-Based Intervention
Family-guided routines based intervention is a systematic approach to embed intervention consistently by all family members and service providers throughout the day rather than in individual, isolated therapy sessions. Routines are functional events of daily living that offer opportunities to teach and practice meaningful skills in settings and situations, as they are needed. By definition, they occur on a regular basis and are repeated frequently, offering multiple opportunities for teaching and learning. Family-guided routines are those functional and predictable activities that match the interests and individual schedules of the child and family. The family guides the selection of appropriate targets and contexts for intervention. Routines that are selected for intervention are predictable and positive for both the child and care provider to enhance the ease of use and the potential for positive outcomes.
Developmental, Individual differences, Relationship-based (DIR) Approach
The Developmental, Individual differences, Relationship-based (DIR) Approach was developed by Drs. Stanley Greenspan and Serena Wieder and focuses on the child’s social-interaction development, primarily the core processes of relating, attending, communicating, and thinking. These processes are targeted through a set of strategies known as “floortime” play with the child. “Floortime” is a series of reciprocal child-directed interactions resulting in “communication circles.” The goal of “floortime” is to sustain interactions between the child and the adult by gradually increasing the circles of communication. These interactions become the basis for further play development.
During “floortime,” the adult joins in the child’s play to increase opportunities for pleasurable interaction and engagement. The child’s actions are considered intentional and purposeful. The adult follows the child’s lead to validate the child’s sense of “self.” Preferred objects and activities are used to motivate the child and facilitate persistence and patience. Higher level skills and concepts are taught through interactive play.
Relationship Development Intervention (RDI)
Relationship Development Intervention is a cognitive-developmental treatment program developed by Dr. Steven Gutstein. RDI focuses on family empowerment in which parents are trained to act as participant guides, creating daily opportunities for their child to respond in more flexible, thoughtful ways to novel, challenging and increasingly unpredictable settings and problems. The RDI approach targets core areas of “dynamic intelligence” including declarative communication, referencing, regulating, episodic memory, and flexible thinking. Parents are taught to re-think their daily lifestyle, structuring activities throughout the day to provide safe, but challenging opportunities for discovery.
Integrated Play Groups Model
The Integrated Play Groups Model was developed by Dr. Pamela Wolfberg at San Francisco State University to enhance peer relations and social development in children with autism. The model consists of three main steps, including thorough assessment, play group development, and guided participation. IPG assessments identify the child’s level of functioning and preferences across several skill areas and play domains. Integrated playgroups, consisting of a small group of children with diverse abilities, are then specifically tailored around the child’s strengths, interests, and target objectives. Play sessions are structured by establishing routines and rituals that foster familiarity, predictability and a cohesive group identity with an emphasis on using visual aids. Guided participation is enacted through a carefully designed system of support. The play guide methodically guides novice and expert players to engage in mutually enjoyed play activities that encourage social interaction, communication, play and imagination. Play guides apply a key set of practices including monitoring play initiations, scaffolding play, and providing social-communication and play guidance.
Sensory Intervention Plans
Sensory processing refers to the ability of the central nervous system to take in and respond to environmental input from all of the senses, including vision, hearing, touch, responses to movement and pressure on the body, taste, and smell. Self-regulation refers to the ability to maintain a calm, alert, and attentive state, which promotes involvement in learning experiences and interaction with others. Many people with autism are believed to demonstrate atypical reactions to sensory input. The self-stimulatory or perseverative behaviors exhibited by persons with autism are possibly attempts to seek out calming and organizing sensory input or to avoid disorganizing input from the environment. Examples of difficulty with sensory processing and self-regulation may include:
• Excessive jumping, running, or spinning which indicates a need for vestibular (movement of the head through space) and proprioceptive (movement and position of the body) input
• Biting, sucking, and chewing excessively which indicates a need for proprioceptive input through the mouth
•Excessive toughing or avoidance of touching which indicates atypical reactions from the tactile (touch) system
• Agitated behavior or under-responsive behavior in loud, crowded, or visually stimulating situations which indicates over-reactivity to noise, touch, or visual input.
Difficulties with sensory processing and self-regulation can be addressed through careful assessment of the individual student’s needs. A sensory intervention plan is developed based on the specific sensory needs of the child. The learning environment is modified to reduce sensory defensiveness and enhance self-regulation. Specific activities are planned throughout the student’s day to promote better attention and engagement in learning.
Assistive Technology
Assistive technology is any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. The most widely used assistive technology applications for young children with autism include those that address communication skills.
Low Tech Augmentative Communication Aids
Strategies and devices that supplement speech skills are typically termed “augmentative communication” approaches. Materials that do not have electronic components are often referred to as “low tech” augmentative communication aids and include picture symbol communication boards and books. For preliterate children, words and concepts are represented by photographs or picture symbols which accompany the printed words. Messages are communicated by pointing to the corresponding picture symbols or by handing the picture symbol to a communication partner.
High Tech Voice Output Communication Aids
Augmentative communication devices, which have electronic components, are often referred to as “high tech.” Those devices permit an adult to program corresponding spoken messages for the picture symbols selected for the child. The child is able to communicate the messages by selecting a picture symbol. The spoken message often provides a model for the child and cues the child to say the word or phrase. Use of the voice output communication device also permits the child to communicate more effectively in group situations than use of low tech communication aids.
Source: http://www.hcpss.org/special/eis_treatment.pdf
Teaching Strategies from Council for Exceptional Children Website
When teaching students with autism, educators must consider the child's social, communication, and academic needs. Thus, teachers must offer a broad array of accommodations to help them cope with the turmoil of school interactions, as well as provide structure and adaptations that enable them to master subject content.
To start, Shore recommends that teachers observe their students with autism to learn how they react in particular situations and their likes and dislikes. Shore also cautions that teachers must not see these students as a bundle of symptoms.
"A student with autism is a thinking person, not a collection of behaviors that need to be changed," he says.
Some additional strategies to help students with autism succeed are:
Organization and Structure
- Provide visual cues. Since most students with autism are visual learners, visual cues can be a lifeline. They inform students of the rules, their schedule, and changes in their routine. For example, the teacher can create a person locator system on a bulletin board, which shows students what they will do and with whom that day, says Simpson. If a teacher will be absent, take the teacher's picture off and tell the student, "In her place, we have Mr. Todd."
- Don't remove visual supports too soon. Instead, find ways the students can be more independent by using them. While it's cumbersome to carry around a Velcro board outlining the day's schedule, students could use something like a day planner, recommends Simpson.
- Provide appropriate levels of structure. Set up routines for class activities such as writing on the board an outline of what was covered yesterday, what the class will do today, and what that will lead to tomorrow.
- Use schedulers or organizers to help students keep track of their activities for a day.
- Write down lesson objectives.
- Provide keyboards. Students with autism often have difficulty writing, which impedes their ability to take notes or write long assignments. Other options include a peer note-taker or providing advance notes, which help students with structure and content mastery.
- Use priming techniques. Familiarize students with material before it is introduced in class and show how new content fits into previous knowledge. This prevents students from shutting down when new material is introduced. Or, review the schedule at the beginning of the school day, which gives the student a heads up on upcoming assignments, books, and activities.
- Provide extra testing time and verbal tests.
- Use graphic organizers and highlight significant concepts. This prevents students from focusing on minutia.
- Use peer buddies who prompt students to follow verbal directions.
- Teach the hidden curriculum - what is important to certain teachers and social protocols.
- Use the students' interests to relate to content.
- Ask students what they need: where they are comfortable sitting, what they need for lectures.
- Consider a reduced schedule or scheduling the student's most difficult class later in the day.
- Make sure the student understands the content when the lesson moves to abstract concepts.
Behavior ControlVisual supports can also be used for task analysis, says Simpson. For free time, the cue may show a picture of activity choices such as a computer or book. Then the visuals outline the steps to take: get material, sit in this area and work on item one, clean up, return to seat.
Academic Accommodations
Many of the academic strategies that work for students with autism are those used with students with learning disabilities, such as:
- Conduct functional behavior assessments. Some children with autism have "odd behaviors they use to communicate," says Grimm. Students may hit or grab someone when unsure what will happen next or if they are thirsty and can't ask for a drink. Communication is further complicated by the fact that the same behavior may have different functions in different settings. Once the teacher determines the behavior's function, he or she should develop a functional communication system for the student. Both the assessment and communication system should be set up before the child is placed in an inclusive class, Grimm says.
- Have a home base for students. Home base is a place where students can go to regroup when they become overstressed. Students can also go there to review and interpret the day's events, says Myles. Home base should never be used as punishment.
- Allow students to change classes early or pair with another student, so they don't feel overcrowded in the halls.
- See "Meltdowns" for recommendations for these behaviors. Social Skills Use the student's interests to help them make friends, e.g. find a club the student could join.
- Do "social autopsy." Help the student analyze a situation, discover what went wrong, develop alternate solutions, and plan strategies to use when similar situations occur. The teacher may want to write down the strategies so the student has a script of what to say.
- Set up social skills groups in which the student can learn and practice social skills. The group may include students with autism and general education students who serve as role models or others who are shy or otherwise need help with social skills.
- Offer alternatives to stressful situations such as the lunchroom, gym, or other places that are noisy, have lots of sensory input, and require students to interact with peers on their own. Allow the student and a few others to eat in a smaller room where social skills can be practiced. For gym, give the student head phones or make another student a buddy and perform a physical activity in another location.
- Provide peer buddies. Have general education students work as social translators for students with autism.
- Allow students to role play social situations to learn appropriate ways to interact with others and make friends.
- Provide group work. While group work is critical, Safran says, it must be done with care. The student with autism should have a peer buddy, or the teacher should pre-define student roles. The student with autism should be assigned specific tasks and someone should monitor his or her progress. A good way to prepare students for group work is through role playing.
- Give students visual cues to help them deal with different social situations, says Webber. Cards the teacher provides would give the student various responses to specific situations.
- Use social stories to help students learn how to make friends.
New StrategiesSome new strategies have emerged that may further help students with autism. New York University's Barbara Hummel-Rossi developed a methodology that enables students with autism to problem solve. It allows them to explore on their own while providing support. The student is given a task and a set of materials with which to work to reach a solution. Afterwards, the students can use the problem solving process they learned in new situations.
The Miller Method is a cognitive development technique that uses the student's desire to do something to teach communication. Here the instructor teaches the student a routine for an enjoyable activity, such as going down a slide. After the student knows the routine, the teacher interrupts at the moment of maximum tension, when the student most wants to continue the activity. This is where we have the greatest likelihood of communication, says Shore. When the student realizes he or she is stopped - and before the tantrum - there will be communication.
Videos are also being used to help students with autism learn social skills. A program developed by Lisa Burger, Jeanine Thomas, and Ann Bodden-Griffen of Easter Seals DuPage, Ill., combines a video of a social interaction such as playing doctor, a written script, and occupational therapy (OT). The OT helps the children be ready to learn; the script, in the form of a picture book, provides visual reinforcement for the video; and the video shows the students what to do and say in an interaction.